Double Trouble: A Case of Ictal Bradycardia Syndrome Complicating Temporal Lobe Epilepsy

Abstract Ictal bradycardia (IB) is an uncommon and serious extraneural manifestation of epilepsy. We describe the case of a patient with temporal lobe epilepsy, who, despite appropriate antiepileptics, developed status epilepticus with pharmacologically refractory bradycardia. Electrocardiogram showed features of a complete heart block with the right bundle branch block and escape rhythms. A temporary pacemaker was inserted, in addition to antiepileptics for seizure control. He maintained intrinsic heart rhythm, and since discharge, has not suffered further seizures. IB probably result from massive parasympathetic discharge from the insula and limbic system. It occurs in <1% of seizures, usually in temporal lobe epilepsy, regardless of the presence of structural cardiac anomalies. Longer duration arrhythmias can cause asystole and syncope and could be fatal. Our report highlights the role of central autonomic centers in severe bradycardia, and adds to the body of the literature regarding this rare phenomenon.